| Extrinsic
compression by tuberculous mesenteric nodes is the rarest form of duodenal
obstruction. Herein we report case of obstruction of the third part of
Duodenum due to Tuberculous lymphadenitis, the presentation of which resembled
superior mesenteric Artery syndrome. The limitations of clinical evaluation,
radiology and endoscopy are stressed and value of laparotomy is highlighted. |
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Introduction
Isolated obstruction of the third part of Duodenum is rare. Causes of
infrapapillary duodenal obstruction includes - midgut
volvulus with transduodenal band, duodenomesocolic band, superior mesenteric
artery syndrome, tumours of pancreas, duodenal neoplasia, traumatic or
infiammatory strictures and pressure by lymphnodes. Obstruction of third
part of duodenum due to extrinsic compression by tuberculous lymphnodes
is uncommon and one such case is presented. |
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CASE
REPORT
A 17 year old female, presented with complaints of pain in upper abdomen
with vomiting after having food since 3 months.
Pain in abdomen was relieved after vomiting. History of low grade fever
since 2 months. No history of haematemesis and
pulmonary kochs. On clinical examination upper abdomen was distended with
succussion splash. There was no hyperperistalsis. Blood investigations
revealed, Hb - 11.5 gm%, ESR - 85 mm/hr. Rest of the blood chemistry were
within normal range. Chest Skiagram revealed right midzone consolidation.
Barium meal revealed distended stomach, first and second part of duodenum
with delayed transit of barium to intestine suggestive of obstruction
of 3rd part of duodenum. Upper GI scopy showed no intra luminal mucosal
lesions but stomach and duodenum was roomy. CT scan abdomen revealed distended
stomach and duodenum till third part of duodenum, suggestive of superior
mesenteric artery yndrome. Laparotomy was done which revealed multiple
lymphnodes at root of mesentery and around the third part of duodenum,
compressing duodenum, with dilatation of proximal duodenum and stomach.
Duodenojejunostomy was done to bypass obstructed third part of duodenum.
Lymphnode biopsy was done. Histopathology of mesenteric lymphnode was
suggestive of tuberculosis. Patient was started on 4 drug antituberculous
chemotherapy. Postoperative recovery was uneventful patient had 2 kg of
weight gain on follow up after 1 month and was symptomless on regular
follow up. |
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Fig. 1 : Barium meal showing dilated
stomach and duodenum |
Fig. 2 : CT scan showing narrowing of third part
of duodenum and dialted 2nd part |
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Fig. 3 : Intra-operative photograph showing
lymph node mass at the root of the mesentery |
Fig. 4 : Intra operative photo showing dilated
stomach and duodenum |
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DISCUSSION
Gastrointestinal tuberculosis is still rampant in our country and can
mimic other GI diseases. Isolated duodenal involvement is uncommon. Tuberculosis
of GI tract most often affects the ileocaecal region.1 Involvement of
stomach and
duodenum is rare.1 This is attributed to the presence of acid, rapid transit
of gastric contents past the duodenum, and the paucity of lymphoid tissue
in the region.2 Duodenal involvement accounts for only 2.5% of TB enteritis.1
The disease may be extrinsic or intrinsic or both.1 In the extrinsic type
there can either be primary duodenal involvement or compression due to
enlarged tuberculous lymphnodes at the root of mesentery. Three types
of lesions are recognized with intrnsic involvement ulcerative, hypertrophic
and ulcerohypertrophic.1 The third part is the most commonly affected
site in the duodenum.3
Usually patients are in second and third decade of life and more common
in females.4,5 The clinical manifestations of duodenal TB are varied and
nonspecific. Our patient had features of outlet obstruction. In a series
of 30 patients two types
of presentation were recognized. Twenty two had features of obstruction
while 8 had mainly dyspeptic symptoms.4 The patients of duodenal obstruction
present with pain in abdomen relieved by vomiting with presence of succussion
splash.5,6 Fever and weight loss may be present. An epigastric mass may
be palpable in 33% of patients.7 Active ulmonary tuberculosis can be seen
in some of the patients but the incidence of pulmonary kochs with alimentary
kochs is not consistent.1 The radiological features are suggestive of
distal duodenal obstruction, but there are no specific
radiological features suggestive of duodenal tuberculosis. Endoscopy may
not be diagnostic and biopsies obtained show only nonspecific inflammatory
changes.8 In our case, the barium studies showed massively dilated stomach,
first and
second part of duodenum with a narrow cut off in the third part of duodenum.
CT scan abdomen was suggestive of superior mesenteric artery syndrome.
Differentiation from other causes of extrinsic pressure may not be easy
particularly superior mesenteric artery syndrome which is more common.6,9
Laparotomy with histological examination of the lymphnodes is necessary
for a definitive diagnosis.4-6,8 Duodeno jejunostomy is ideal, but may
not always be possible due to caseating nodes in the vicinity6 and gastrojejunostomy
may
be the only alternative available. We have done duodenojejunostomy for
our patient.
The complications of duodenal TB other than obstruction are gastrointestinal
bleeding, perforation and fistula formation with other parts of gastrointestinal
tract and even the kidney aorta4,10-12 and obstructive jaundice due to
occlusion of
common bile duct.13 |
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CONCLUSION
Duodenal tuberculosis being an uncommon form of intestinal tuberculosis
poses great difficulty in diagnosis. High index of suspicion supported
by radiological investigation, exploratory laparotomy and histopathological
examination of the tissue biopsy can only lead to a definitive diagnosis
of this rare condition. Surgical treatment involves bypassing the lesion
and antituberculosis therapy. |
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REFERENCES
1. Paustian FF, Marshall JB. Intestinal tuberculosis. In Berk EJ, Hallbrich
WS, Kaiser MH, et al, eds. Gastroenterology, vol-3, fourth edition, Philadelphia:
W 13 Saunders. 1985 : 2018-36.
2. Tandon RK, Pastakia B. Duodenal tuberculosis as seen by duodenoscopy.
Am J Gastroenterol 1976; 66 : 483-6.
3. Reader MM, Philip ESP. Infections and infestations. In Margulis RA,
Burbene JH, eds. Alimentary tract radiology.
St Louis : LV Mosby 1989 : 1478-9.
4. Gupta SK, Jain K, Gupta AP, et al. Duodenal tuberculosis. Clin Radiology
1988 : 159-61.
5. Gupta SD. Duodenal tuberculosis. Indian Journal of Surgery 1971; 33
: 123-5.
6. Davey WW, Pearson JB. Obstruction of third part of Duodenum. Br J Surgery
1965; 52 : 189-93.
7. Gleason T, Prinz RA, Kirsch EP, et al. Tuberculosis of the duodenum.
Am J Gastroenterology 1979; 72 : 36-40.
8. Batikian JP, Yenikamashian SN, Jidejan YD. Tuberculosis of the pyloroduodenal
area. AJR 1967; 101 : 414-20.
9. Kriplani AK, Kumar S, Sharma LK. Obstruction of the third part of the
duodenum in tuberculosis. Postgrad Med J 1986; 62 (731) : 879-80.
10. Smith DR. Kidney infections. In: Smith DR ed. General urology. California
: Lange Medical Publications. 1979 : 397-8.
11. Schwartz PT, Garner HA, Lattimer JK, et al. Pyeloduodenal fistula due
to tuberculosis. J Urology 1970; 104 : 373-5.
12. Edic DGA, Pollock DS. A complicated aortoduodenal fistula. Br J Surg
1968; 55 : 314-7.
13. Shah P, Ramakant R, Deshmukh H. Obstructive jaundice unusual complication
of duodenal tuberculosis. Indian J of
Gastroenterology 1991; 10 (2) : 62-3. |
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CHLAMYDIA
IN MEN
‘Our finding shows.... the importance of involving men
as well as women in opportunistic testing for chlamydia’
In the UK, the frequency of genital Chlamydia trachomatis infection
has been found to be lower in young men than in young women. However,
few data are available from settings other than genitourinary
medicine clinics, and results may have been biased by low response
rates. Louise McKay and colleagues tested male military recruits
in Scotland for chlamydia as part of routine medical examinations.
The 9.8% rate of infection among these men was greater than that
usually cited, with a high rate of asymptomatic infections, and
similar frequencies in all age groups. These findings highlight
the importance of opportunistic chlamydia testing in men, and
the need to identify potential settings for such screening.
Lancet, Neurology, 2003; 1792. |
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